lev-os Managing Allergic Conditions Pediatric
Guides the evaluation and management of pediatric allergic conditions including food allergy, allergic rhinitis, atopic dermatitis, drug allergy, insect venom allergy, and anaphylaxis. Covers testing modalities (skin prick, specific IgE, component-resolved diagnostics), oral food challenge protocols, epinephrine action plan creation, and allergen immunotherapy considerations.
Why This Skill Exists
Allergic disease affects over 30% of children, and food allergy prevalence has increased by 50% in the last two decades. Misinterpretation of allergy testing is rampant — a positive specific IgE or skin prick test indicates sensitization, NOT clinical allergy. Unnecessary dietary restrictions based on test results alone lead to nutritional deficiency, social isolation, and paradoxically increase the risk of developing true allergy (per the LEAP study findings). This skill enforces proper test ordering, results interpretation in clinical context, evidence-based management, and structured emergency action planning.
Checkpoint A — Intake Verification
Required Intake Questions
- What is the suspected allergic condition (food allergy, allergic rhinitis, eczema, drug allergy, anaphylaxis)?
- What is the specific allergen exposure history (substance, timing, route, amount)?
- What symptoms occurred and their timing relative to exposure (immediate < 2 hours vs. delayed)?
- Has the child ever had anaphylaxis? If so, describe the event and treatment received.
- Does the child have an epinephrine auto-injector? Is it current (not expired)?
- What is the child's history of atopic disease (eczema, asthma, allergic rhinitis — the atopic triad)?
- What is the family history of allergic disease?
- What dietary restrictions are currently in place and who recommended them?
- Has the child had prior allergy testing (skin prick, specific IgE, oral food challenge)?
Required Documents
- Prior allergy test results (specific IgE levels, skin prick test records)
- Current dietary restriction list with rationale for each
- Anaphylaxis action plan (if exists)
- Medication list (antihistamines, epinephrine, inhalers)
- Growth chart (to assess impact of dietary restrictions)
Step 1 — Allergic Condition Classification
IgE-Mediated (Immediate) Reactions
- Onset: minutes to 2 hours after exposure
- Symptoms: urticaria, angioedema, vomiting, wheezing, hypotension, anaphylaxis
- Conditions: food allergy (IgE-mediated), allergic rhinitis, acute urticaria, anaphylaxis, drug allergy (Type I), venom allergy
Non-IgE-Mediated (Delayed) Reactions
- Onset: hours to days after exposure
- Symptoms: eczema flare, chronic diarrhea, bloody stools, failure to thrive
- Conditions: food protein-induced enterocolitis syndrome (FPIES), food protein-induced proctocolitis, eosinophilic esophagitis (EoE)
- Testing: specific IgE and skin prick are NEGATIVE in non-IgE-mediated conditions; diagnosis is clinical
Mixed IgE/Non-IgE
- Atopic dermatitis (eczema): both IgE and non-IgE mechanisms; food triggers in ~30% of moderate-severe eczema in young children
Step 2 — Allergy Testing and Interpretation
Skin Prick Testing (SPT)
- Wheal ≥ 3 mm greater than negative control = positive
- Positive SPT = sensitization, NOT necessarily clinical allergy
- Positive predictive value is poor (~50%); negative predictive value is excellent (> 95%)
- Antihistamines must be withheld: cetirizine/loratadine ≥ 3-7 days; diphenhydramine ≥ 3 days before testing
Specific IgE (sIgE) Blood Testing
- ImmunoCAP is the standard platform
- Results reported in kU/L; higher levels correlate with higher (but not certain) likelihood of clinical reactivity
- 95% predictive decision points (Sampson criteria) for common foods:
Allergen sIgE Level (≥ 95% PPV) For Children < 2y Egg white ≥ 7 kU/L ≥ 2 kU/L Milk ≥ 15 kU/L ≥ 5 kU/L Peanut ≥ 14 kU/L — Tree nuts Varies by nut — Fish ≥ 20 kU/L —
Component-Resolved Diagnostics (CRD)
- Measures IgE to specific allergenic proteins within a food
- Peanut: Ara h 2 is the strongest predictor of clinical allergy (> 0.35 kU/L highly associated)
- Milk: Cas (casein) IgE predicts persistent allergy; Bos d 8 correlates with reactivity to baked and unheated milk
- Egg: Gal d 1 (ovomucoid) predicts reactivity to baked egg; Gal d 2 and Gal d 4 may indicate tolerance to baked egg
- CRD helps avoid unnecessary avoidance and guides oral food challenge decisions
Oral Food Challenge (OFC)
- Gold standard for food allergy diagnosis
- Indications: equivocal test results, suspected tolerance development, confirm or exclude clinical reactivity
- Must be performed in supervised medical setting with resuscitation equipment
- Graded doses administered every 15-30 minutes over 2-4 hours; observation for 2 hours after final dose
- Positive challenge: objective symptoms (urticaria, vomiting, wheezing, hypotension)
- Negative challenge: food can be reintroduced into diet
Step 3 — Food Allergy Management
Allergen Avoidance
- Written dietary avoidance plan with specific allergen names, cross-reactive foods, and label-reading guidance
- Educate on FALCPA (Food Allergen Labeling and Consumer Protection Act): top 9 allergens must be declared; precautionary labels ("may contain") are voluntary and unregulated
- Dietitian referral to ensure nutritional adequacy when major food groups are eliminated (especially milk, egg, wheat, soy)
Epinephrine Action Plan (Anaphylaxis Emergency Plan)
Every child with IgE-mediated food allergy must have:
- Epinephrine auto-injector prescribed (EpiPen Jr 0.15 mg for 7.5-25 kg; EpiPen 0.30 mg for > 25 kg)
- Written anaphylaxis action plan with:
- Allergen(s) identified
- Signs/symptoms of anaphylaxis (two or more organ systems involved)
- Instructions: administer epinephrine FIRST, then call 911; antihistamines are adjunctive, NOT a substitute for epinephrine
- Biphasic reaction warning: observe for 4-6 hours after anaphylaxis (late phase in ~20% of cases)
- Auto-injector training for patient, family, and school nurse
- Two auto-injectors available at all times (school + home/carried)
Peanut Allergy: Early Introduction (LEAP/LEAP-ON)
- Per AAP/NIAID 2017 Addendum Guidelines:
- High-risk infants (severe eczema ± egg allergy): introduce peanut-containing foods at 4-6 months after evaluation (SPT or sIgE)
- Moderate-risk (mild-moderate eczema): introduce around 6 months
- Low-risk: introduce freely with other complementary foods
- Early introduction reduces peanut allergy risk by up to 80% in high-risk infants (LEAP trial)
Oral Immunotherapy (OIT) and Biologics
- Peanut OIT (Palforzia): FDA-approved for ages 4-17; daily escalating doses under medical supervision; reduces severity of reactions but does not cure allergy; must continue daily maintenance
- Omalizumab (Xolair): anti-IgE monoclonal; FDA-approved as adjunct for food allergy ages 1+; enables tolerance of larger accidental exposures
- Both require allergist management; not for primary care initiation
Step 4 — Allergic Rhinitis Management
Diagnosis
- Symptoms: sneezing, nasal congestion, rhinorrhea (clear), nasal pruritus, postnasal drip
- Allergic shiners, allergic salute, Dennie-Morgan lines, nasal crease
- Confirm with SPT or sIgE to aeroallergens
Stepwise Therapy
| Step | Treatment |
|---|---|
| Mild intermittent | Oral antihistamine PRN (cetirizine, loratadine, fexofenadine) |
| Moderate/persistent | Intranasal corticosteroid daily (fluticasone, mometasone) |
| Refractory | Add intranasal antihistamine (azelastine) or LTRA (montelukast — see FDA warning) |
| Severe/refractory | Subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT) |
Allergen Immunotherapy
- SCIT: weekly injections for build-up (3-6 months), then monthly maintenance (3-5 years)
- SLIT: sublingual tablets (grass, ragweed, dust mite) for ages 5+; daily at home after first dose observed
- Both modify disease course: reduce new sensitizations and reduce asthma development risk in children with allergic rhinitis
Step 5 — Atopic Dermatitis and Drug Allergy
Atopic Dermatitis (Eczema) — See Also Dermatology Skill
- Food allergy testing in eczema: only test for clinically suspected triggers; do NOT "panel test" broadly
- Emollient-first approach: apply moisturizer (ointment > cream > lotion) immediately after bathing
- Topical corticosteroids: low potency (face, skin folds), medium (body), use for flares
- Dupilumab: FDA-approved for moderate-severe atopic dermatitis ages ≥ 6 months
Drug Allergy Evaluation
- Most reported "penicillin allergies" in children are NOT true allergy (< 5% confirmed on testing)
- Penicillin allergy evaluation: skin testing + graded oral challenge can de-label > 90% of patients
- Benefits of de-labeling: avoids unnecessary use of broader-spectrum antibiotics, reduces C. difficile risk, reduces cost
Checkpoint B — Allergy Management Review
- Allergic condition classified (IgE-mediated vs. non-IgE vs. mixed)
- Detailed exposure and reaction history documented
- Appropriate testing ordered and interpreted in clinical context (not in isolation)
- Dietary restrictions evidence-based (not based on sensitization alone)
- Epinephrine auto-injector prescribed with written action plan
- Auto-injector training documented for family and school
- Dietitian referral made if major food groups eliminated
- Early allergen introduction counseled (peanut per LEAP guidelines)
- Allergic rhinitis managed per stepwise approach
- Growth monitored if dietary restrictions are in place
- Immunotherapy discussed if appropriate (refractory rhinitis, venom allergy)
- All [VERIFY] flags resolved or escalated
Quality Audit
| Item | Requirement | Pass? |
|---|---|---|
| Test interpretation | Sensitization vs. clinical allergy distinction documented | |
| Clinical context | Testing correlated with exposure history before restricting diet | |
| Epinephrine plan | Written plan with auto-injector prescribed and training done | |
| Nutritional adequacy | Dietitian referral if restricting milk, egg, wheat, or multiple foods | |
| Early introduction | Peanut introduction counseled per NIAID guidelines for high-risk infants | |
| Growth chart | Weight/height monitored for impact of dietary restrictions | |
| Anaphylaxis protocol | Two auto-injectors, school plan, biphasic observation | |
| Drug allergy | Penicillin allergy de-labeling considered if applicable | |
| Rhinitis management | Stepwise therapy applied; montelukast risk discussed | |
| No unexplained [VERIFY] tags | All flagged items resolved or escalated |
Guidelines
- Follow NIAID 2010 Guidelines for Diagnosis and Management of Food Allergy (updated with 2017 Addendum for peanut)
- Apply LEAP trial evidence for early peanut introduction in high-risk infants
- Use Sampson criteria for 95% predictive decision points in sIgE interpretation
- Follow PRACTALL consensus for atopic dermatitis management in children
- Follow AAP/ACAAI/JCAAI guidelines for allergic rhinitis stepwise therapy
- Montelukast: FDA black box warning for neuropsychiatric events — discuss risk/benefit
- Palforzia (peanut OIT): FDA-approved ages 4-17; requires REMS program enrollment
- Omalizumab: FDA-approved for food allergy ages 1+ as of 2024
- Epinephrine is FIRST-LINE for anaphylaxis — antihistamines are adjunct only
- Component-resolved diagnostics (Ara h 2, Gal d 1, etc.): use to refine risk assessment when available
- Do not order "allergy panels" without clinical indication — panels generate false positives that lead to unnecessary restrictions
- This skill produces clinical documentation; it does not replace clinical judgment